We carried out a review of the data available to us about Werrington Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Werrington Lodge, you can give feedback on this service.
Werrington Lodge is a residential care home providing personal and nursing care to up to a maximum 82 people. The service provides support to mainly older people some of whom are living with dementia. At the time of our inspection there were 51 people using the service.
People’s experience of using this service and what we found
People felt safe living at the service. Risk assessments had been completed to ensure that action was taken to keep people safe where possible.
Staffing levels meant that people were safe and they received their care in a timely manner. People received their medication as prescribed. There were systems in place to record, monitor and learn from accidents and incidents.
Staff had the knowledge, skills and support they required to meet people’s needs effectively. People’s physical, emotional and social needs were identified so staff could meet these.
People received support with eating and drinking when needed. People were supported to maintain good health and were supported by or referred to the relevant healthcare professionals.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff were calm, kind and gentle in their interactions with people and supported them to remain independent whilst maintain their safety and welfare. People's privacy and dignity was maintained. Staff were caring and compassionate as they supported people
People were consulted about their care and had been given information in an accessible way. People were supported to pursue their hobbies and avoid the risk of social isolation. People were treated with compassion at the end of their lives so they had a dignified death.
The home was well managed. The provider had systems in place to monitor the quality of the service. Actions were taken and improvements were made when required.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (report published September 2019).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Werrington Lodge on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
The service was only receiving essential visitors at the time of our inspection. Any person entering the building undertook a rapid flow test (RFT), which gives a COVID-19 test result within 30 minutes. Visitors also had their temperature taken, completed a health questionnaire and wore full personal protective equipment (PPE).
People who had been confirmed as being COVID-19 positive were supported by staff in full PPE. This is called barrier nursing. This is to protect both staff and people living in the service from spreading infection. All staff had received training in the correct use of PPE, and how to take it off and put it on safely.
The manager told us that they had changed systems within the service to reduce the spread of infection. For example, staff did not mix between units, and the units used different entrances and operated separate rotas. Staff had also been supported to find alternative travel arrangements into work to avoid the use of public transport, for example using the cycle to work scheme.
Whole home testing was carried out on both people and staff. Staff undertook an RFT test on each shift, and also the standard weekly test.
Cleaning of the home, including frequently touched surfaces, had increased to reduce the risk of transmission of infection. Additional domestic staff had also been brought into the service.
Werrington Lodge is a residential care home providing personal and nursing care to 63 people, at the time of the inspection. The service can support up to 68 people.
People’s experience of using this service and what we found
Staffing levels did not always meet people’s needs or ensure their preferences were met. People told us they had to wait for their support and this included the time they were supported from their bed. Medicine practices when administering medicines needed to improve to ensure safe practice and medicine given when required (PRN) needed to be in place for all people who required them.
People’s records and care plans were person centred and important details and preferences considered. People's preferences were not always delivered in practice as there were not always enough staff on duty to meet everyone’s needs in a timely manner. Care plans were not always updated with the appropriate information.
People told us they felt safe. Staff received appropriate training and knew how to keep people safe. Staff supported people safely, but it could take a longer time to complete tasks due to staffing levels.
Staff had assessed people’s needs and completed risk assessments. People told us they had plenty to eat and drink. However not all fluid charts we looked at had the appropriate target recorded to ensure staff understood what amount was required for people to achieve their daily target.
People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People said the staff were very caring and kind and treated them well. They told us staff maintained their privacy and provided the care they wanted.
People did have formal opportunities to give their views on the service and felt confident to do so if needed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 2 February 2019).
Why we inspected
This was a planned inspection based on the previous focused inspection rating. We have found evidence that the provider needs to make improvements. Please see safe, effective, responsive sections of this full report. You can see what action we have asked the provider to take at the end of this full report.
Follow up
We will continue to monitor the information we receive about the service until we return to visit as per our re-inspection programme. progress. If we receive any concerning information we may inspect sooner.
Following our last inspection on 25 April 2018, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe, responsive and well led to at least good.
We undertook an unannounced focused inspection of Werrington Lodge on 14 November and 17 December 2018. This inspection was carried out to check the provider had carried out the improvements following our last inspection.
We inspected the service against three of the five questions we ask about services: is the service safe, responsive and well led? This is because the service was not meeting some legal requirements. We found improvements had been made, the legal requirements had been met and the home is now rated good in all areas. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection”.
At the time of the inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the previous inspection we found that the administration and management of medication was not always safe. Staff had made improvements to the systems and procedures to ensure that people received their medication as prescribed. The administration of medication was being recorded accurately, appropriate information was available about when medication should be administered. Regular checks were being completed to identify any issues so they could be dealt with promptly.
During the previous inspection we found that people did not always receive care and support that was based on their individual needs and preferences. Staff had worked hard to improve people’s care plans so that they included personal information for staff to follow when working with people.
Staff were aware of how to keep people safe from harm and what procedures they should follow to report any harm. Action had been taken to minimise the risks to people. Risk assessments identified hazards and provided staff with the information they needed to reduce risks where possible.
At the previous inspection we found that areas for improvement were not always identified. Improvements had been made. There was an effective quality assurance process in place which included obtaining the views of people that lived in the home, their relatives and the staff. Where needed action had been taken to make improvements to the service being offered.
Staff were only employed after they had completed a thorough recruitment procedure. Staff received the training they required to meet people's needs and were supported in their roles.
There was a varied programme of activities including activities held in the home, trips out and entertainers that came into the home.
There was a complaints procedure in place. People and their relatives felt confident to raise any concerns either with the staff or manager. Complaints had been dealt with appropriately.
Werrington Lodge accommodates 82 people in one purpose built building. At the time of the inspection there were 61 older people living in the home.
The inspection took place on 25 and 27 April 2018 and was unannounced. At the previous inspection in September 2017 the home was rated as good overall. At this inspection we found it had deteriorated to requires improvement.
At the time of the inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People’s health was placed at risk because they were not always receiving their medicines as prescribed. The medication administration records had not always been completed accurately. Staff had not always followed instructions for how some medicines should be administered such as half an hour before food. Medicines were stored securely.
Although risk assessments had been completed staff were not always aware of or had not followed the guidance. This placed people at risk to their health and safety. Staff were aware of safeguarding procedures and what action they should take if they suspected anyone was at risk of harm. Incidents and accidents were analysed so that action could be taken to prevent a reoccurrence.
Staffing levels were sufficient to meet people’s basic needs but this was not always done in a timely manner. The home was using a tool to analyse how many staffing hours were required. The registered manager was trying to recruit to a new twilight shift to ensure people’s needs were met in a more timely way. Safe recruitment practices were followed to ensure staff were suitable to work in a care home. Staff received the training and support they required.
People were provided with a choice of food and drink that they enjoyed. When needed, people received the support they needed from staff to eat and drink. The monitoring of food and drink intake for people at risk of malnutrition or dehydration was not always completed accurately.
People were supported by kind and caring staff. Staff noticed when people became anxious and gave them the reassurance they needed. People's privacy and dignity were upheld. People and their relatives had been asked their views on the quality of the service and what improvements
could be made so that they were involved in the running of the home. Visitors were made to feel welcome to the home. People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.
Care plans did not always provide staff with the information that they required to meet people's individual care and support needs. This meant that they were at risk of not having their needs met in a person-centred way.
The systems being used to assess, monitor and improve the service provided were not always effective. This was because not all areas requiring improvement had been identified.
We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
This unannounced inspection took place on 8 September 2017. At the last inspection on 19 September 2016 the service was rated as ‘good’. At this inspection we found overall the service remained ‘good’.
A registered manager was in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
When people had sustained unexplained bruising this had not always been reported to the appropriate agencies. This limited staff’s ability to ensure people’s care was as safe as possible. Staff completed training and competency assessments before administering medication to people. Staff were aware of how to reduce risks to people to try and keep them safe. Staff were only recruited after the necessary pre-employment checks had been completed. There were enough staff working in the home to meet people’s needs.
Staff received the training and support they required to carry out their roles effectively. People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service supported this practice.
People received the support they needed to ensure they had adequate food and drink that they enjoyed. People were referred to the relevant healthcare professionals whenever this was needed.
Staff supported people in a kind and caring manner which promoted their dignity and privacy. People’s relatives and friends were encouraged to visit and made to feel welcome. If needed people were supported to make decisions about their care.
Care plans were detailed and provided staff with the current information they required to meet people’s needs. People were supported to take part in activities that promoted their emotional, physical and spiritual well-being. People were confident to raise any concerns they had and felt that they would be dealt with appropriately.
There was an effective quality assurance system in place to identify any areas for improvement. Staff and people living in the home were encouraged to be involved in the running of the home and give their views on any improvements needed.
Further information is in the detailed findings below.
This comprehensive inspection took place on 19 September 2016 and was unannounced.
The provider is required to have a registered manager as one of their conditions of registration.
A registered manager was not in post at the time of the inspection although the provider had recently appointed a new manager who was yet to start in their new post. The provider told us on 22 August 2016 that it was their aim for the new manager to become registered with the Care Quality Commission (CQC) A registered manager is a person who has registered with the CQC to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were kept safe and staff were knowledgeable about reporting any incident of harm. People were looked after by enough staff to support them with their individual needs. The provider aimed to reduce the number of agency staff by recruiting permanent staff into vacant positions. Pre-employment checks were completed on staff before they were assessed to be suitable to look after people who used the service. People were supported to take their medicines as prescribed. The provider was taking action to improve some deficiencies in the management of people’s prescribed medicines to reduce the risk of any harm.
People were supported to eat and drink sufficient amounts of food and drink. They were provided also with choices of food and drink to meet their individual dietary preferences and requirements. People were helped to access health care services. This was to ensure that their individual health needs were met.
The CQC is required by law to monitor the Mental Capacity Act 2005 [MCA 2005] and the Deprivation of Liberty Safeguards [DoLS] and to report on what we find. The provider was aware of what they were required to do should any person lack mental capacity. People’s mental capacity was assessed and people were able to make decisions about their day-to-day care. Staff were knowledgeable about the application of the MCA.
People were looked after by staff who were trained and supported to do their job. The provider was taking action to increase the level of individual supervision for all staff members.
People were looked after by kind staff who treated them with respect and dignity. They and their relatives were given opportunities to be involved in the setting up and review of people’s individual care plans.
Care was provided based on people’s individual needs and helped to reduce the risk of social isolation. There was a process in place so that people’s concerns and complaints were listened to and action was taken to address them.
There were interim management arrangements pending the start of a new manager. The manager was supported by a team of management staff, ancillary staff and a team of nursing and care staff. Staff were supported and managed to look after people in a safe way. Staff, people and their relatives were able to make suggestions and actions were taken as a result. Quality monitoring procedures were in place and action was taken where improvements were identified.
Werrington Lodge is a registered care home and provides accommodation, support and care, including nursing care, for up to 82 people, some of whom live with dementia. At the time of our inspection there were 55 people living at the home. There are two individual units with ‘Memory Lane’ being the name of the unit where people live with dementia. The care home is located in a residential suburb of the city of Peterborough.
A registered manager was not in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We carried out an unannounced comprehensive inspection of this service on 13 November 2014. A breach of a legal requirement was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the inconsistent application of approved safe moving and handling practices by some staff members.
We undertook this focused inspection on 08 April 2015 to check that the provider had followed their plan and to confirm that they now met legal requirements.
This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk
At our focused inspection on the 08 April 2015, we found that the provider had followed their plan which they had told us would be completed by the 31 January 2015 and legal requirements had been met.
People told us and we saw that they were safely supported with their moving and handling needs. The staff on duty knew the people they were supporting and demonstrated their knowledge when supporting people with their individual moving and handling needs.
Staff had received additional training in relation to supporting people with their moving and handling and they and their records confirmed that they had received this training.
Werrington Lodge is a registered care home and provides accommodation, support and care, including nursing care, for up to 82 people, some of whom live with dementia. At the time of our inspection there were 55 people living at the home. There are two individual units with ‘Memory Lane’ being the name of the unit where people live with dementia. The care home is located in a residential suburb of the city of Peterborough.
The registered manager was not in post and not managing the regulatory activities at this location at the time of the inspection. An application was in progress to register the current home manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The inspection was unannounced and was carried out on 13 November 2014 by three inspectors and a pharmacist inspector. This is an inspector who has specialist knowledge in relation to medicines.
Following our last inspections of 08 and 12 May 2014 and the follow up inspection of 12 June 2014, the provider was issued with warning notices because there were breaches of Regulation 14 (1) (a) and (c), Regulation 17(1) (a) and (2) (a), Regulation 9 (1) and Regulation 10 (1) (a) (b). We returned on 21 August 2014 to check if the provider had taken action to address the concerns raised. We found that the provider had taken the required action to meet the requirements set out in the warning notices.
In addition to the warning notices, we had made other requirements as there were breaches of Regulation 11(1) (a), Regulation 12, Regulation 18, Regulation 19 (1) (a) and 2 (a)(b)(c)(d), Regulation 20 (2)(a), Regulation 21(a)(i)(b) and Regulation 22. The inspection of 13 November 2014 found that the provider has taken the required action to meet the requirements of the regulations.
During this inspection we found that improvements had been made in relation to infection control and cleanliness of the premises. In addition, there were improvements in how new staff were recruited and people were now looked after by enough staff. There was also an improvement in the reporting of incidents of harm to people, to the appropriate local authorities. Although people said they felt safe, improvements were needed in relation to the consistent application of safe moving and handling techniques.
People were supported to eat and drink sufficient amounts of food and drink. They were also supported to access a range of health care services and people living with dementia had their individual communication needs understood and these needs were met. People’s rights in making decisions and suggestions in relation to their support and care were valued and acted on. Where people were unable to make these decisions, they were supported with this decision making process. Individual recreational and social hobbies and interests were provided to maintain and promote people’s sense of wellbeing. Staff were trained and supported to do their job.
The CQC monitors the operation of the Mental Capacity Act 2005 (MCA 2005) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. We found that people’s rights were being protected as DoLS applications were in progress and had been submitted for the authorising agencies to consider.
People were treated well by respectful and attentive staff and they and their relatives were involved in the review of people’s individual care plans.
People received care that was responsive to their individual needs and they were supported to maintain contact with their relatives and the local community. Improvements had been made in relation to complaints made to the manager. People’s concerns and complaints were listened to and these were acted upon to the satisfaction of the complainant.
The care home was better managed than at previous inspections and was safe for people to live, visit and work in. Staff enjoyed their work and were supported and managed to look after people in a caring and safe way. Improvements were made in how people’s confidential information was stored and kept up-to-date. Staff, people and their relatives made suggestions at meetings and actions were taken as a result. Quality monitoring procedures were in place and action was taken where identified improvements were needed.
Werrington Lodge is care home providing accommodation and nursing care for up to 82 adults. There were 78 people living there when we visited on 12 June 2014. The care home provides a service for people with physical nursing needs and for people living with mental health or dementia. The home comprises two units that each provides differing care services. There is currently an interim manager at the home.
During the course of our two day inspection on 08 and 12 May 2014 we had found significant concerns about the care people were receiving in the home and we took immediate action to safeguard them. We issued the provider with three warning notices as they had been breaches in Regulation 14(1)(a) and (c), Regulation 17(1)(a) and (2)(a) and Regulation 9(1) of the Health and Social Care Act 2008. We asked the provider to be compliant with these regulations by 30 May 2014.
We returned on 12 June 2014 to check if the provider had taken action to address the concerns raised and if they could demonstrate compliance with the warning notices.
We found that there had been some improvement in the care that people received, however, we found that there were a number of continued breaches in the Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2010 at Werrington Lodge. You can see what action we told the provider to take at the back of the full version of the report.
Werrington Lodge is care home providing accommodation and nursing care for up to 82 adults.
There were 79 people living there when we visited. The care home provides a service for people with physical nursing needs and for people living with mental health or dementia. The home comprises of two units, one for older people who require nursing and another for people who live with a dementia related illness. There is a manager registered at the service.
During the course of this two day inspection we found significant concerns about the care people received in the home and we took immediate action to safeguard them. This included passing information to the Local Authority for them to look at under their safeguarding vulnerable adults procedures. We also met with health professionals who were funding people’s care and with the registered person to escalate our concerns and ask for immediate action to be taken. The registered person has told us what actions they will be taking to improve the service and the steps they will be taking to make sure people receive the care they should. The service is being monitored closely by us and Commissioners.
We found the home was not clean and people were at risk of acquiring a health associated infection. People were not protected from the risk of abuse and their rights under the Mental Capacity Act 2005 were not taken into account.
People were not protected from the risks of developing pressure ulcers or from falls. Staff were not monitoring or supporting people when they were nutritionally at risk and people were not given appropriate help with drinks.
We saw a lack of care and compassion for people with staff ignoring their shouts for help and assistance. Staff did not show respect for people in relation to their privacy and dignity.
There was a lack of stimulation offered to people and there were no effective systems in place to support people to have a say in how they were cared for.
We saw a lack of leadership and direction given to staff and although there were systems in place to monitor the quality of the service, these were not effective and action had not been taken to address failings identified in the home.
The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. (The deprivation of liberty safeguards is a code of practice to supplement the main Mental Capacity Act 2005 Code of Practice.) The Mental Capacity Act (MCA) 2005 is an act introduced to protect people who lack capacity to make certain decisions because of illness or disability.
We looked at whether the service was applying the Deprivation of Liberty safeguards (DoLS) appropriately. These safeguards protect the rights of adults using services by ensuring that if there are restrictions on their freedom and liberty these are assessed by professionals who are trained to assess whether the restriction is needed. We found the location may not be meeting the requirements of the Deprivation of Liberty Safeguards.
We found there were a number of breaches in the Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2010 at Werrington Lodge and you can see what action we told the provider to take at the back of the full version of the report.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
The inspection was unannounced and the purpose of it was to check if the provider had met the requirements of the warning notices which were issued following our inspections undertaken on 08 May 2014 and 12 May 2014 and our last inspection of 12 June 2014. The provider was issued with the warning notices because there had been breaches of Regulation 14(1) (a) and (c), Regulation 17(1) (a) and (2) (a), Regulation 9 (1) and Regulation 10(1) (a) (b). We returned on 21 August 2014 to check if the provider had taken action to address the concerns raised and if it could demonstrate that it had met the requirements set out in the warning notices.
Werrington Lodge is registered to provide accommodation, support and care, including nursing care, for up to 82 mainly older people. There were 64 people living there when we visited on 21 August 2014. The care home provides a service for people with physical nursing needs and for people living with dementia. The care home offers two individual units that each provides differing services. There is currently an interim manager in post.
We found that the provider had taken the required actions that we had set out in the warning notices. Improvements had been made in how people were being looked after. They were now being respected and had the care and support to meet their health and social needs.
People had the right amounts of food and drink to promote their good health and were offered choices from the menu of what they would like to eat. We also found improvements in the management and leadership of the home. Staff were organised, caring and felt they were now listened to. In addition, there was an overall improvement in how the provider found areas that needed improving and the effective actions they had taken in making these areas better. This included, for instance, the environment and the cleanliness of the home.
People's care was provided and was based upon their assessed care needs. People could be confident that their care needs were safely met.
Following the receipt of concerning information, the provider took steps to ensure that people were safe and that any potential risk to people was effectively managed. Information on how to contact the safeguarding authority and the provider was available throughout all units of the service. People and staff were supported to report abuse if they ever suspected this. Safeguarding of vulnerable adults (SOVA) information which had been provided to the Care Quality Commission confirmed that this was the case.
People's plans of care were person centred. People told us that the care at Werrington Lodge was, "Amazing." We saw that care plans had been reviewed regularly which ensured that people were cared for based upon their most up-to-date health care information.
Staff we spoke with were knowledgeable on who and how to report any safeguarding of vulnerable adults (SOVA) concerns and the different types of abuse. Staff told us that they felt confident that if they raised any concerns with the manager that these were dealt with appropriately.
Medicines administration records (MARs) we reviewed were without error or omission. People were assured that they would be administered their prescribed medication at the correct time.
Staff were able from time to time to gain additional healthcare qualifications. Training records we reviewed demonstrated to us that staff's training was kept up-to-date and reflected changes in legislation and guidance.
Records of people's health care plans we reviewed were up-to-date. We saw records for all statutory inspections such as Legionella, electricity and gas safety checks.
One relative who we spoke with said, "My mum wouldn't be here today if it wasn't for her being at Werrington Lodge, she is just so happy there".
Another person told us, "I have been here for quite some time, there isn't anywhere else I would rather live as I have made so many friends".
People and relatives told us that they were involved in deciding what their health care needs were and how these were to be met. We found that staff were given comprehensive training that enabled them to meet people's needs whatever they might be.
We spoke with relatives and one of them told us, "The overall quality of the home is good, the nurses and care staff are excellent". "The service is absolutely first class; I have never met such nice members of staff".
We also found that people were protected from abuse because the home had an up-to-date safeguarding policy and provided staff with training. People were provided with information within the home that enabled people to contact the correct authority should they need to report incidents of abuse.
We found that the care home had an effective quality assurance system that identified and managed risks that people could be affected by.